Provider Demographics
NPI:1811005101
Name:SMIDDIE, KELLIE A (LISW)
Entity type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:A
Last Name:SMIDDIE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14587 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107
Mailing Address - Country:US
Mailing Address - Phone:216-521-5050
Mailing Address - Fax:216-521-8797
Practice Address - Street 1:14587 MADISON AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107
Practice Address - Country:US
Practice Address - Phone:216-521-5050
Practice Address - Fax:216-521-8797
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14902104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker